Provider Demographics
NPI:1912065228
Name:FAZZALARO, WILLIAM (PA-C)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:FAZZALARO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:447 OLD NEWPORT BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4257
Mailing Address - Country:US
Mailing Address - Phone:949-650-3350
Mailing Address - Fax:949-650-1274
Practice Address - Street 1:447 OLD NEWPORT BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4257
Practice Address - Country:US
Practice Address - Phone:949-650-3350
Practice Address - Fax:949-650-1274
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16754363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1750339479OtherGROUP NPI
CAPA16754OtherLICENSE
CAPA16754OtherLICENSE
CAMF0948212OtherDEA